Providers of social services have traditionally had to wait long periods of time to get paid for their services. These providers have been required to extend credit to individuals with insurance in order to get paid. This situation has become tedious and causes social services costs to be very high.
A need has long existed for a system, wherein the government advances funds so that the individual does not have to handle money.
This need has been particularly great for incapacitated individuals, such as those in nursing homes, who are no longer able to handle funds or complicated transactions.
The cost of health care continues to increase as the health care industry becomes more complex, specialized, and sophisticated. The proportion of the gross domestic product that is accounted for by health care is expected to gradually increase over the coming years as the population ages and new social services become available.
Over the years, the delivery of health care services is not only from individual physicians but also from large managed health maintenance organizations, hospitals, pharmacists, and mental health therapists. There are growing numbers of social services specialists in a complex variety of health care options and programs to service the increasing populations, which has increased in elderly populations.
Unfortunately, the payment for the delivered health care is now occurring much later than the delivery of the service. Increasingly, health care providers are acting as credit institutions for the individual because of the lack of governments to timely provide funds under a policy.
The cost of supporting patient costs has increased during recent years, thereby contributing to today's costly health care system. A significant portion of the increase in the cost of social service is caused by the administrative costs represented by the systems for creating, reviewing and adjudicating health care provider payment requests. Such payment requests typically include bills for procedures performed and supplies given to patients. Currently, the systems for reviewing and adjudicating payment requests represent additional health care transaction costs that directly reduce the efficiency of the health care system and increases the cost of the health care delivered.
A need exists to reduce the magnitude of transaction costs involved in reviewing and adjudicating payment requests that would have the effect of reducing the rate of increase of health care costs.
A need exists for streamlining payment request review and adjudication that would also positively increase the portion of the health care dollar that is spent on treatment rather than administration.
A need exists to reduce the traditionally high cost of health care administration, including the review and adjudication of payment requests which results from health care service providers having to act as “banks” or “credit sources” for patients.
A need exists to facilitate the understanding of the contractual obligations between the service provider and the individual. Often, there are many different contractual arrangements between different patients, governments, and health care providers. The amount of authorized payments may vary by the service or procedure, by the particular contractual arrangement with each health care provider, by the contractual arrangements between the government and the patient regarding the allocation of payment for treatment, and by what is considered consistent with current social service practice.
During recent years, the process of creating, reviewing, and adjudicating payment requests from health care providers has become increasingly automated. For example, there exist claims processing systems whereby technicians at health care providers' offices electronically create and submit social service claims to a central processing system. The technicians include information identifying the physician, patient, social service, government, and other data with the social service. The central processing system verifies that the physician, patient, and government are participants in the claims processing systems. If so, the central processing system converts the social service request into the appropriate format of the specified government, and the claim is then forwarded to the government. Upon adjudication and approval of the insurance claims, the government initiates a check to the provider. In effect, such systems bypass the use of the mail for delivery of insurance claims. However, there is no known system for accelerated payment of funds within only a day or two of the claims presentation.
In partially automated systems, such as that described in the foregoing example, the technician can submit a claim via electronic mail on the Internet or by other electronic means. To do so, the technician establishes communication with an Internet service provider or another wide area network. While communication is maintained, the technician sends the insurance claim to a recipient and then either discontinues communication or performs other activities while communication is established. Using such conventional systems, individual at the health care provider's office are unable to determine whether the submitted claim is in condition for payment and do not receive any indication, while communication is maintained, whether the claim will be paid.
Because of the large number of governments and insurance plans, the amount of the co-payment can vary from patient to patient and from visit to visit. Moreover, when a patient is not covered for a certain treatment, the patient may be liable for the entire amount of the health care services. It is sometimes difficult for technicians at the office of the health care provider to determine that amount of any co-payment or any other amount due from the patient, such as a deductible that must be collected while the patient remains at the office after a social service visit. Once the patient leaves the office, the expense of collecting amounts owed by patients increases and the likelihood of being paid decreases. Conventional insurance claim submission systems have not been capable of efficiently and immediately informing technicians at the offices of a health care provider of amounts owed by patients, particularly when the amount is not a fixed dollar amount. A need has been desired, particularly by patients (individual) and health care providers for a solution to this dilemma.
Other methods and apparatus exist to attempt to streamline the insurance claim payment process, such as the method disclosed in Gamble U.S. Pat. No. 6,163,770. This patent reveals using a digital electrical apparatus to generate output for insurance documentation for a first insurance policy having a first risk and claims while revealing a concurrent second insurance policy for a second risk, wherein the second risk is different from the first. The processor of this method is connected to a memory device for storing and retrieving operations including machine-readable signals in the memory device, to an input device for receiving input data and converting the input data into input electrical data, to a visual display unit for converting output electrical data into output having a visual presentation, to a printer for converting the output electrical data into printed documentation, wherein the processor is programmed to control the apparatus to receive the input data and to produce the output data by steps including: inputting actuarial assumptions defining the first insurance policy; and computing a value of a specific financial attribute of the first insurance policy; the method further including the step of inserting the value of the financial attribute in the first insurance policy and other printed documentation related to the first insurance policy.
In view of the foregoing, there is a need for a more fully automated claims processing system that have the ability to have an accelerated pay schedule and an ability to reduce the uncertainty as to whether a claim to be submitted is likely to be paid or rejected.
The present invention has been developed to provide an accelerated claims processing system that would easily allow health care providers to know what patient and treatment information must accompany insurance claims, whether or not a patient is eligible for accelerated fee payment, and to obtain funds quickly against rendered services from insurance companies.